Coach Julia's Client Questionnaire

CLIENT QUESTIONNAIRE

Thank you for completing this questionnaire. The information provided will help us tailor your training and/or nutrition plan to your needs. Please answer all questions as accurately as possible. This form is confidential and will only be used by Coach Julia.
Date

MonthDayYear
Date
Name

First NameLast Name
Permanente Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
AGE
DATE OF BIRTH

MonthDayYear
Date
Height
(ex. 5'8)
WEIGHT
(ex. 140 lbs)
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE- (PAR-Q)

The PAR-Q will inform you if you should consult your doctor before making significant changes to your physical activity routines if you are between the ages of 15 and 69. Consult your doctor if you are over 69 and not accustomed to being active. PLEASE READ THE QUESTIONS CAREFULLY AND ANSWER HONESTLY. YES or NO
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

YESNO
Do you feel pain in your chest when you do physical activity?

YESNO
In the past month, have you had chest pain when you were not doing physical activity?

YESNO
Do you lose your balance because of dizziness or do you ever lose consciousness?

YESNO
Do you have a bone or joint problem that could be made worse by a change in your physical activity?

YESNO
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

YESNO
Do you know of any other reason why you should not do physical activity?

YESNO
If you answered YES to one or more questions

You should consult with your doctor to clarify that it is safe for your to become physically active at thiscurrenttimeandinyourcurrentstateofhealth.

If you answered NO to all questions

You can be reasonably sure that it is safe for you to participate in physical activity, gradually building up from your current ability level. A fullfitness appraisal can help to determine your fitness.

Confirmation Statement

I have read, understood and accurately completed this questionnaire. I have been advised to consult with my doctor if I answered YES to any question above prior to starting a new personal training program. My signature confirms I am assuming the responsibility to do so and any risk of my failure to do so and confirms that I am voluntarily engaging in a acceptable level of exercise, and my participation involves a risk of injury.
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HEALTH HISTORY

Present & Past Health History
Have you had, or currently have, any of the following? (Check all that apply)

Heart AttackChest PainHeart MurmurPalpitations or ArrhythmiaHeart Surgery of any typeUndiagnosed pain or discomfort in the chest, neck, arms, or other areasUnusual fatigue or shortness of breath at rest or light activityDiabetesPrediabetesHypoglycemicHigh Blood PressureLow Blood PressureKidney DiseaseHigh CholesterolLung DiseaseAsthmaShortness of breath while lyingAllergiesSeizuresCancerFainting or DizzinessMuscle or Joint ProblemJoint ReplacementEdemaBlurred or Temporary loss of clear vision or speechNumbness or weakness in a limb or of your bodyLow Bone Density, osteopenia, or osteoporosisPelvic Floor Dysfunction symptoms (bladder leaks, urgency, incontinence, pelvic prolapse, back pain, painful intercourse, constipation, bowel) incontinenceDegenerative brain conditions (Parkinson's, Alzheimer's, or similarOther not list condition
IF YOU CHECKED ANY OF THE ABOVE, PLEASE PROVIDE DETAILS BELOW.
Please list any past injuries or surgeries.
If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance from a doctor to return to physical activity?

YesYes, but I am still receiving treatment or PT.No, I have not been released yet.
FAMILY HEALTH HISTORY
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)

Heart AttackCongenital Heart DiseaseHigh Blood PressureHigh CholesterolHeart SurgeryDiabetesOther
IF YOU CHECKED ANY OF THE ABOVE, PLEASE PROVIDE DETAILS BELOW. (who and at what age)
MEDICATIONS

Please list all that you are taking below
FITNESS - Experience & Goals

Please share your current fitness routine and goals to help us tailor your training plan. Skip this section if you’re only interested in nutrition coaching.
How would you rate your current fitness level?

1

2

3

4

5

6

7

8

9

10

1 is Unfit, 10 is Very fit
How long has it been since you exercised regularly?
ON A SCALE FROM 0 (not important) TO 10 (extremely important), HOW IMPORTANT ARE THE FOLLOWING FITNESS GOALS TO YOU?
WEIGHT LOSS

1

2

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5

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7

8

9

10

1 is Not Important, 10 is Extremely Important
MUSCLE GAIN

1

2

3

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5

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7

8

9

10

1 is Not Important, 10 is Extremely Important
GAIN STRENGTH (Become stronger)

1

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3

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5

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7

8

9

10

1 is Not Important, 10 is Extremely Important
IMPROVED CARDIOVASCULAR ENDURANCE

1

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5

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7

8

9

10

1 is Not Important, 10 is Extremely Important
HEALTH MARKER IMPROVEMENTS

1

2

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5

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7

8

9

10

1 is Not Important, 10 is Extremely Important
SPORTS PERFORMANCE

1

2

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5

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8

9

10

1 is Not Important, 10 is Extremely Important
IMPROVED JOINT MOBILITY

1

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5

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7

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9

10

1 is Not Important, 10 is Extremely Important
IMPROVED BALANCE

1

2

3

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5

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9

10

1 is Not Important, 10 is Extremely Important
IMPROVED BONE DENSITY

1

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5

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9

10

1 is Not Important, 10 is Extremely Important
How many days per week do you get at least 45-60 minutes of exercise?
Please list the physical activities that you participate in outside of the gym and how often: (yoga, Pilates, walking, running, golf, pickleball, tennis, etc.)
Do you wear a fitness tracker? (Apple Watch, FitBit, or similar)

YESNO
If yes, how many steps have you average per day over the last month?

less than 2,0002,001 - 4,0004,001 - 6,0006,001 - 8,0008,001 - 10,00010,001 - 12,00012,001+
What type of equipment have you used? (Check all that apply.)

Free-weightsMachinesBodyweight movementsTreadmillBike (indoor or outdoor)Cross-trainerStairmasterEllipticalRowerOther
Are you comfortable with strength training or learning to strength train? If not, please explain.
Is there anything in your past or current fitness routine that you have felt to be particularly beneficial or that you loved?
Is there anything in your past or current fitness routine that you have felt NOT particularly beneficial or disliked?
What are your primary fitness goals (short-term and long-term)?
Is there anything that would help you adhere to a training plan?
Is there anything that might hinder you from adhering to a training plan?
Are there any specific body parts or areas that you would like to focus on?
Have you worked with a personal trainer/coach before? If yes, tell me about the experience. What did you like or dislike? If no, tell me what has held you back if anything?
Realistically, how many days per week can you dedicate to a new strength training routine?

12345+
How disciplined are you prepared to be to achieve your goals?

1

2

3

4

5

1 is Ugh! I am dreading this!, 5 is I am all in!
NUTRITION - Past, Present and Goals

Please share your current eating habits and nutrition goals to help us tailor your coaching plan. Skip this section if you’re only interested in fitness training.
Tell me about your nutrition goals.
On a scale of 0 (not healthy) to 10 (very healthy), how would you rate your overall diet?

1

2

3

4

5

6

7

8

9

10

1 is Not healthy, 10 is Extremely healthy
How would you rank your daily salt intake?

LowMediumHigh
How would you rank your daily sugar intake?

LowMediumHigh
How would you rank your daily fat intake?

LowMediumHigh
Do you think you consume enough protein in your daily diet?

Yes, I believe I get plenty through my meals and snacks.No, I suspect I'm not getting enough.I'm unsure—I don't track it closely or know the recommended amounts.
Do you have any dietary preferences (e.g., vegan, vegetarian, gluten-free)? If yes, please specify.
Have you followed any popular diets previously (e.g., Atkins, Keto, Paleo)? If yes, how did that go?
Do you have a history of eating disorders? If yes, please provide details
NOTE BELOW HOW MANY MEALS YOU EAT AWAY FROM HOME EACH WEEK.

(Meals you do not make for yourself. Meals purchased away from home.)
BREAKFAST - Meals eaten out each week
LUNCH - Meals eaten out each week
DINNER - Meals eaten out each week
How often do you eat fast food?

Very rarely1 time per week2-3 times per week4 or more times per week
Do you snack after dinner?

Very rarelyOccasionallyMore often than not
On a scale of 0 (no control) to 10 (always), how effectively can you control temptations for junk food?

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10

1 is No control, 10 is Always
LIFESTYLE and WELLNESS

Your lifestyle impacts your fitness and nutrition plans. Please provide details about your daily habits and routines.
Do you feel you get enough sleep and wake up feeling rested?

NEVERRARELYOCCASIONALLYOFTENALWAYS
What is your occupation or type of work?
What hobbies or recreational activities do you enjoy?
On a scale of 1 (no stress) to 10 (extreme stress), how would you rate your average stress level

1

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3

4

5

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7

8

9

10

1 is No stress, 10 is Extreme stress
How many caffeinated beverages (e.g., coffee, tea, soda, energy drinks) do you consume per day?

012345+
How many alcoholic drinks do you have per week?

01-34-67+
Describe your tobacco or vaporizer use.

NeverIn the past, but not now.Occasionally, but not dailyDaily
ADDITIONAL INFORMATION

Is there anything else I should know to help tailor your training or nutrition plan?
Share any other information you feel would be valuable below:
Should be Empty:

CLIENT QUESTIONNAIRE

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE- (PAR-Q)

HEALTH HISTORY

FAMILY HEALTH HISTORY

MEDICATIONS

FITNESS - Experience & Goals

NUTRITION - Past, Present and Goals

LIFESTYLE and WELLNESS

ADDITIONAL INFORMATION